Comment
AIDS responses can and must continue to transform
societies—but this task requires increased, not decreased,
investment. A priority for UNAIDS in 2010 is to support
UN Secretary-General Ban Ki-moon’s leadership in the
third voluntary replenishment of the Global Fund to
Fight AIDS, Tuberculosis and Malaria. Without it, the
AIDS response will be severely challenged even to sustain
the gains we have made.
As we approach the deadline for universal access
to HIV prevention, treatment, care, and support,
we are convinced that UNAIDS is on the right
path—the path of prevention and the path that links
the transformative AIDS response to health and
development.
Michel Sidibé, *Kent Buse
Joint United Nations Programme on HIV/AIDS (UNAIDS),
1211 Geneva 27, Switzerland
busek@unaids.org
We declare that we have no conflicts of interest.
1 UN General Assembly. Declaration of commitment on HIV/AIDS.
June 25–27, 2001. http://data.unaids.org/publications/irc-pub03/
aidsdeclaration_en.pdf (accessed Jan 25, 2010).
2 Ottosson D. State-sponsored homophobia: a world survey of laws
prohibiting same sex activity between consenting adults. May, 2009.
http://ilga.org/statehomophobia/ILGA_State_Sponsored_
Homophobia_2009.pdf (accessed Jan 25, 2010).
3 UNAIDS. Mapping of restrictions on the entry, stay and residence of people
living with HIV. June, 2009. http://data.unaids.org/pub/Report/2009/
jc1727_mapping_en.pdf (accessed Jan 25, 2010).
4 US Department of Health and Human Services. Immigration regulations
and HIV/AIDS. Jan 4, 2010. http://www.aids.gov/federal-resources/
policies/immigration/#short-term-travel (accessed Jan 25, 2010).
Global health is public health
Last year, in The Lancet, Jeffrey Koplan and colleagues1
provided a new definition for global health and
proposed several distinctions between global health,
international health, and public health. This attempt
to distinguish differences between global health and
public health conflicts with the key tenets of a global
public health strategy (panel). These tenets offer the
foundation of a redesigned global health system that
could accomplish the optimum level of health for
populations. This approach has profound implications
for training, scholarship, and practice necessary to
improve human health.
Global health and public health are indistinguishable.
Both view health in terms of physical, mental, and social
wellbeing, rather than merely the absence of disease.
www.thelancet.com Vol 375 February 13, 2010
5 Starrs AM. Lessons and myths in the HIV/AIDS response. Lancet 2009;
374: 1674–75.
6 England E. Lessons and myths in the HIV/AIDS response. Lancet 2009;
374: 1674.
7 Kaoma K. Globalizing the culture wars: U.S. conservatives, African
churches, and homophobia. 2009. http://www.publiceye.org/
publications/globalizing-the-culture-wars/pdf/africa-full-report.pdf
(accessed Jan 25, 2010).
8 UNAIDS, WHO. AIDS epidemic update. November, 2009. http://data.unaids.
org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf (accessed Jan 25,
2010).
9 The Lancet Infectious Diseases. Does HIV/AIDS still require an exceptional
response? Lancet Infect Dis 2008; 8: 457.
10 WHO. Report on the expert consultation on positive synergies between
health systems and Global Health Initiatives. May 29–30, 2008. http://www.
who.int/healthsystems/hs_&_ghi.pdf (accessed Jan 25, 2010).
11 Jaffar S, Amuron B, Foster S, et al, on behalf of the Jinja trial team.
Rates of virological failure in patients treated in a home-based versus
a facility-based HIV-care model in Jinja, southeast Uganda:
a cluster-randomised equivalence trial. Lancet 2009; 374: 2080–89.
12 UNAIDS. Joint action for results: UNAIDS outcome framework 2009–2011.
May, 2009. http://data.unaids.org/pub/Report/2009/jc1713_joint_action_
en.pdf (accessed Jan 25, 2010).
13 Sidibé M. Mobilizing prevention as a movement for universal access. Speech
to the 2009 Programme Coordinating Board. December, 2009. http://data.
unaids.org/pub/SpeechEXD/2009/20091208_pcb_exd_speech_en.pdf
(accessed Jan 25, 2010).
14 Global Network of People living with HIV. http://www.gnpplus.net
(accessed Jan 25, 2010).
15 Piot P, Bartos M, Larson H, Zewdie D, Mane P. Coming to terms with
complexity: a call to action for HIV prevention. Lancet 2008; 372: 845–59.
16 Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, et al, for the MOPH–TAVEG
Investigators. Vaccination with ALVAC and AIDSVAX to prevent HIV-1
infection in Thailand. N Engl J Med 2009; 361: 2209–20.
17 Feuer C, Fisher K, Harmon T, et al. Adapting to realities: trends in HIV
vaccine research funding 2000–2008. 2009. http://www.iavi.org/Lists/
IAVIPublications/attachments/212dc3d7-f753-4b58-b2a6-d04323cc8b98/
HVMRTWG_adapting_to_realities_VaxSummary_2009_ENG.pdf
(accessed Jan 25, 2010).
18 WHO, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/
AIDS interventions in the health sector. Progress report 2009.
September, 2009. http://www.who.int/hiv/pub/tuapr_2009_c1_en.pdf
(accessed Jan 25, 2010).
Both emphasise population-level policies, as well as
individual approaches to health promotion. And both
address the root causes of ill-health through a broad array
of scientific, social, cultural, and economic strategies.
In 1915, the Welch–Rose report established a blue-
print for US public health schools that emphasised
training in discrete interventions, targeted at reducing
infectious diseases.2 Since then, the world’s health
needs have grown more complex, the scientific
opportunities for prevention and treatment more
sophisticated, and the need for coordinated approaches
more urgent. In 2003, the US Institute of Medicine laid
out a much broader vision that recognised the need for
a multisectoral systems-based approach to sustainable
population health.3
535
 Comment
Panel: Key tenets of global public health
• Belief that global health is public health. Public health is
global health for the public good.
• Dedication to better health for all, with particular
attention to the needs of the most vulnerable
populations, and a basic commitment to health as a
human right.
• Belief in a global perspective on scientific inquiry and on
the translation of knowledge into practice, not limited by
political boundaries, but sensitive to contextual issues
that might influence illness, the design or choice of
interventions, or health systems.
• A scientific approach to health promotion and disease
prevention that examines broad determinants of health
including, but not limited to, delivery of medical care, and
creates integrated approaches in clinic, community, and
government.
• Commitment to an interdisciplinary approach and
collaborative team work to analyse problems of
populations. Global concerns, such as climate change, and
cross-disciplinary issues, such as zoonotic diseases and
human health, involve close collaborations between
medicine, public health, veterinary medicine, and many
other disciplines.
• Multilevel systems-based interventions deployed to
address the interactive contributions of societal and
health-governance issues, corporate responsibility, and
environmental, behavioural, and biological risk factors
are key.
• Comprehensive frameworks for financing and
structuring health policies and services that support
community-based and clinical prevention integrated with
health-care delivery and deployment of a balanced
workforce of physicians, nurses, and other providers.
Yet global health is still often perceived as inter-
national aid, technologies, and interventions
flowing from the wealthier countries of the global
north to the poorer countries of the global south.
A more nuanced and contemporary perspective
emphasises interdependence and recognises the many
contributions of both resource-rich and resource-
scarce nations.4 With the new understanding that
many health problems have a linked aetiology and a
common impact, and that innovative solutions can
come from all sectors, collaborative relationships
become, at a minimum, bidirectional—and optimally,
multilateral.
The importance of a global perspective is highlighted
by these observations. First, pandemic infectious
diseases, such as AIDS and influenza, and the health
536
challenges associated with climate change, are not
confined by sovereignty or the extent of nations’
resources. Second, chronic diseases, which already
contribute a major share of the global burden of
disease, will grow with our ageing population.
Increasing evidence suggests that the diet and lifestyle
of high-income nations have “communicable” char-
acteristics. In China, 20% of men are hypertensive,
while nearly 80 million people in India will have
diabetes by 2030.5 Similarly, tobacco-related dis-
eases began in the global north but have become
commonplace in the global south.
Third, cross-national comparisons of health systems
can yield useful insights. For example, the US health-care
system has higher costs yet unimpressive population-
health outcomes compared with many other nations,
suggesting that the US system might be an inappropriate
export to developing countries. Fourth, the health
workforce is becoming globalised. The traditional
model of health professionals from the wealthy north
providing care in the poor south is outmoded. Instead,
the dominant model is the migration of the health
workforce from south to north, with major resource
implications worldwide.
The tenets of global public health (panel) highlight
public health as a public good, benefiting all members
of every society. While local applications must be
contextually appropriate, a domestic focus on popu-
lation health need not compete for attention with
an international focus—in a global health system,
strengthening one strengthens the other.
Medicine and clinical care remain essential pillars
of that system, but the greater payoff comes with
an integrated, multidisciplinary, prevention-oriented
approach in the community as well as in the clinic. In
the USA, human behaviour accounts for 40% of the
risk of premature death, while the social and working
environments account for 20%. Health care, by contrast,
contributes 10% of health outcomes (with genetics
explaining the rest).6 At the same time, every dollar
invested in prevention produces a sixfold return on
investment.7
Public health schools remain at the forefront of efforts
to educate global health experts who are prepared
to confront the global burden of disease. They bring
systems approaches and a focus on prevention science
and evidence-based interventions to that effort, along
www.thelancet.com Vol 375 February 13, 2010

with a multidisciplinary faculty and ties to communities,
public sector agencies, non-governmental organisations,
and government ministries.
New university structures to support synergies in
global health education, research, and service are
welcome. Links with graduate programmes in medicine,
law, international affairs, and a host of bench and social
science programmes can only strengthen the capacity
of future global public health leaders. Opportunities
abound for research collaborations, dual degrees, and
jointly designed interventions at the clinical, community,
and population levels.
The foundation of those partnerships, however,
recognises that global health and public health repre-
sent a single field with a long tradition of bringing
scientifically validated approaches, technologies, and
systems to bear on the world’s most pressing health
needs. Improving the lives of vulnerable populations
depends on continuing advances in this field.
Linda P Fried, Margaret E Bentley, Pierre Buekens,
Donald S Burke, Julio J Frenk, Michael J Klag,
*Harrison C Spencer
Stroke—a call for papers
Stroke accounts for about 10% of deaths worldwide
each year. Although the incidence of stroke in high-
income countries has fallen by about 40% over the
past four decades, the incidence in low-income and
middle-income countries has more than doubled during
this timeframe, and 85% of all strokes now occur in
developing countries.1,2 Advances in the management of
stroke during the past decade have improved outcomes
for patients who have had a stroke.3 However, stroke
continues to present many challenges, not least of
which is the gross underfunding of stroke research
compared with coronary heart disease and cancer.4
To coincide with the 19th European Stroke Conference,
which will be held in Barcelona, Spain, from May 25 to
May 28, 2010, The Lancet and The Lancet Neurology are
issuing a call for papers. We are particularly interested
in original research papers that report the results of
randomised trials, but we will also consider any other
high-quality research that will inform clinical practice. We
www.thelancet.com Vol 375 February 13, 2010
Comment
Mailman School of Public Health, Columbia University, New York,
NY, USA (LPF); Gillings School of Global Public Health, University
of North Carolina, Chapel Hill, NC, USA (MEB); School of Public
Health and Tropical Medicine, Tulane University, New Orleans, LA,
USA (PB); Graduate School of Public Health, University of
Pittsburgh, Pittsburgh, PA, USA (DSB); School of Public Health,
Harvard University, Boston, MA, USA (JJF); Bloomberg School of
Public Health, Johns Hopkins University, Baltimore, MD, USA
(MJK); and Association of Schools of Public Health, Washington,
DC 20005, USA (HCS)
hspencer@asph.org
We represent a working group of the Association of Schools of Public Health
Global Health Committee. We thank Karen L Helsing for her contributions to this
Comment. We declare that we have no conflicts of interest.
1 Koplan JP, Bond TC, Merson MH, et al, for the Consortium of Universities
for Global Health Executive Board. Towards a common definition of global
health. Lancet 2009; 373: 1993–95.
2 Rockefeller Foundation. Welch-Rose report on schools of public health.
1915. http://www.deltaomega.org/WelchRose.pdf (accessed Jan 28, 2010).
3 Institute of Medicine. The future of public health. 1988. http://books.nap.
edu/openbook.php?record_id=10548 (accessed Feb 3, 2010).
4 Colgrove J, Fried, LP, Northridge, ME, Rosner, D. Schools of public health:
essential infrastructure of a responsibly society and a 21st-century health
system. Public Health Rep 2010; 125: 8–14.
5 WHO. WHO global infobase. https://apps.who.int/infobase/report.aspx
(accessed Sept 17, 2009).
6 Schroeder SA. We can do better—improving the health of the American
people. N Engl J Med 2007; 357: 1221–28.
7 Trust for America’s Health. Prevention for a healthier America: Investments in
disease prevention yield significant savings, stronger communities. July, 2008.
http://healthyamericans.org/reports/prevention08 (accessed Feb 3, 2010).
are especially interested in papers that will be presented Published Online
February 5, 2010
at the meeting, but we also welcome other submissions. DOI:10.1016/S0140-
Original research should be submitted via The Lancet’s 6736(10)60170-5
or The Lancet Neurology’s online submission sites
by April 12. If your paper is being presented at the
conference, please let us know in your covering letter the
date, time, and manner of presentation (oral or poster).
Please also state that you are submitting your paper in
response to this call for papers.
Helen Frankish, Richard Turner
The Lancet Neurology, London NW1 7BY, UK (HF); and The Lancet,
London NW1 7BY, UK (RT)
1 Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide
stroke incidence and early case fatality reported in 56 population-based
studies: a systematic review. Lancet Neurol 2009; 8: 355–69.
2 Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and
mortality: estimates from monitoring, surveillance, and modelling.
Lancet Neurol 2009; 8: 345–54.
3 Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008; To submit a paper go to
371: 1612–23. http://ees.elsevier.com/thelancet
or http://ees.elsevier.com/
4 Rothwell PM. The high cost of not funding stroke research: a comparison
with heart disease and cancer. Lancet 2001; 357: 1612–16. thelancetneurology
537